I am writing this letter to highlight an important facet of the psychopharmacological treatment of symptoms in patients suffering from schizophrenia. Many a times, the patient may have distressing symptoms such as delusions and hallucinations that warrant psychiatric treatment. Antipsychotics both typical and atypical are the mainstay of psychiatric treatment and are known to alleviate distressing hallucinations in patients with schizophrenia.[1] Hallucinations have been classified on the basis of sensory modalities in which they are perceived such as visual, auditory, gustatory, sensory, and olfactory, and also on the basis of whether they are soothing (ego-syntonic) or distressing (ego-dystonic) to the patient.[2],[3] The clinical dilemma I wish to highlight is whether treating ego-syntonic hallucinations is warranted in schizophrenia. If a patient feels a sense of security and affection with certain voices speaking to him and he does not want those voices to leave him, are we, as clinicians, correct in treating such symptoms? The patient may often have ego-syntonic hallucinations coexisting with derogatory ego-dystonic hallucinations and delusions that need treatment. Starting a patient on antipsychotic medication or administering a course of electroconvulsive therapy will not just selectively eliminate the distressing symptoms, rather all hallucinations and delusions shall respond to antipsychotic therapy. If the patient in treatment does not wish that certain hallucinations should go away and rather wants them to stay, are we ethically correct in starting pharmacotherapy and eliminating symptoms that caused the patient solace while also providing him relief from distressing symptoms?

We have seen a patient who used to hear his father's voice which was very reassuring and comforting in the face of various distressing voices and delusions that he had as a result of schizophrenia. The patient was started on an atypical antipsychotic (risperidone) and his distressing symptoms reduced. But while he was relieved, he came back for a follow-up consultation very distressed that the voice of his father no longer soothed him and that he longed to hear the same. He developed depressive features due to not hearing that voice and had to be started on an antidepressant (escitalopram) to help him combat the depression he faced. The voices never came back and the patient was lost to follow-up.

There are two probable ways to look at the situation, namely, one where we consider the hallucinations as a symptom and treat the same irrespective of what they mean to the patient as hallucinations keep changing and hallucinations perceived as positive may also take a negative turn in the course of the illness. The caregivers and patient (if having good insight) must be explained the same before treatment is initiated. The second perspective is to look at what negative or positive effect would treating the symptom have and based on the same decide whether to treat. The clinical dilemma is that we do not have control over where an antipsychotic may act and we do not have symptom-specific treatments; hence, while medication may be started to treat delusions or negative hallucinations they may work universally and treat all symptoms even if the patient may wish that certain symptoms do not go away. There are also no data on any neurobiological differences between ego-syntonic and ego-dystonic hallucinations as the ego aspect is a psychological construct while the underlying biology remains the same in case of any form of hallucinations. Sometimes, we have to treat both ego-syntonic and ego-dystonic hallucinations though the patient may not be happy with the disappearance of ego-syntonic hallucinations on treatment. A rather rare but important clinical scenario is whether the clinician must treat ego-syntonic hallucinations when they are the only symptoms present or we should let them be as they are.

My question to clinicians is whether we are correct in our approach. Are we being just in removing certain symptoms which help the patient or are we being clinically correct but morally and ethically wrong? Are we right in using pharmacotherapy to eliminate what the patient desires? Should ego-syntonic hallucinations be treated or should we let them remain? In the event that treatments eliminate them, are we correct in stopping medication in a hope to get those hallucinations back because the patient wants them? What should be the correct clinical approach here – there are no clear clinical guidelines that speak on this issue and it is an issue that may spark a new debate in the management of hallucinations in patients with schizophrenia.